Most UK doctors support assisted dying, a new poll shows: the BMA’s opposition does not represent members

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Dr Proffitt, on behalf of the Association for Palliative Medicine, raises important questions in response to this piece. In reply to specific questions and comments

Doctors.net membership is restricted to doctors registered with the General Medical Council and to medical students. Participants could choose for themselves whether or not to participate and were asked to respond to the statement 'Assisted dying in defined circumstances should now be legalised in the UK'. No additional information was supplied.

Dr Proffitt cites the recent work done on end-of-life care and assisted dying by the BMA in 2016. The author was part of the working party which produced the study and while it was welcome, its remit regarding assisted dying was very limited, looking mainly at the possible effect on the doctor patient relationship. Arguments put forward in regards of this issue were primarily speculative and the report itself acknowledged that contributions from doctors largely reflected pre-formed views on the legalisation of assisted dying. Little investigation was done of the emerging evidence from overseas, which suggests conversations around end-of-life care improve following law change [ http://www.latimes.com/health/la-me-end-of-life-care-20170821-htmlstory.... ]. Nor was any weight given to a Populus poll of 5000 people which found that for 87% of members of the public an assisted dying law would increase or have no effect on their trust in doctors. [ https://www.dignityindying.org.uk/news/patients-trust-doctors-assisted-d... ]. Other aspects of the work have been criticised in greater detail. [ http://blogs.bmj.com/bmj/2016/01/19/end-of-life-care-consulting-patients... ]

Unfortunately, the study was not allowed to contribute to an 'evidence-based debate' at the BMA ARM because the definitive vote on assisted dying policy was taken the day before the major discussion of the subject itself. For an account of events, including an initial wrecking motion proposing that the ARM should not be debating assisted dying at all (which just under half of attendees supported), please see here

Dr Proffitt is concerned that members of the public will erroneously think that the BMJ speaks for doctors. But the same assumption is made by the public and politicians about the BMA, as evidenced by the fact that BMA policy on assisted dying is quoted in every parliamentary debate on the subject. If the BMA is to speak for doctors on such an important issue they must know what their views are. As things stand they do not. It is difficult to see why the views of the 198 people who voted against adopting a neutral stance at the 2016 ARM should carry more weight than the views of those who participated in the doctors.net poll.

Another rapid response mentions the views on assisted dying of those interviewed for the series BMA Confidential. Amongst the interviewees who answered the question 43% were supportive of assisted dying, 39% opposed, and 18% gave an unclear or neutral answer.

Clearly there is significant appetite within the medical profession for the law to change. In the absence of the membership-wide poll on the subject that the BMJ has called for, a neutral stance from the BMA and others is the most appropriate, fair and scientific way to reflect the division in opinion that evidently exists.

The poll referred to in this article demonstrates the problems with polls. They can be used by one side or the other. The point is there is great division between doctors on this question and the arguments are around the balance of individual rights against collective rights. Every time this argument has been thoroughly debated, looking at this very balance, the arguments against euthanasia have trumped those for because at the end of the day there is far more to be lost by society as a whole - in terms of the creep in subtle utilitarian attitudes, the massive shift in the role of a doctor and the excess lives lost due to these factors over and above the life being deliberately removed.

There is a wealth of evidence to support the certainty of these outcomes. Emotional responses are important. I hear and respond to them every day as a GP, but they do not make sound policy for society which has to protect ALL its citizens. Any shift in this policy breaks a code that has protected the most vulnerable in our society for thousands of years.

There is often a disconnect between theory and practice. Previous interviewees for the BMJ confidential were asked for their opinion on assisted dying. My (subjective) recollection of the answers was that the further the doctor was from regular coal-face clinical practice, the more likely the answer was to be in the negative. To address the disconnect described by Godlee & Davis, perhaps our senior colleagues need to revisit clinical work, or we need to select leaders who represent common medical opinion.

On your website you have featured an article with the heading that a 'new poll' shows that 'most UK doctors support assisted dying'. The article refers to an October 2017 poll on the doctors.net website. So far as we have been able to establish, the only such poll at around that time was one which asked respondents to agree or disagree (strongly or otherwise) with the statement that 'the time has come to legalise assisted dying'. We would welcome your confirmation that this is the poll to which you refer as the article lacks a specific reference for the poll.

If that is so, it is necessary to ask some further questions. First, bearing in mind the statement in the article that "733 people participated" (our italics), we would like to know whether the poll was open to persons other than qualified medical doctors. Second, were participants selected according an established and recognised sampling method? Or was it left to individuals to reply who happened to see the poll by chance or who may have accessed the website in order to participate having learned that such a poll was being conducted? And, third, what (if any) information was given to respondents - for example, what the term 'assisted dying' involved or what kind of legal regime was proposed?

These are vital methodological questions to be asked of an article that makes two such bold claims in its headline: that “Most UK doctors support assisted dying” and that the BMA does not represent its members” on the subject.

The article notes that the BMA is opposed to legalisation of 'assisted dying' and states that "BMA policy is the result of a debate attended by around 400 delegates", the inference being that BMA policy is decided on the basis of little more than a show of hands. This is not true. The BMA recognises the complexities and sensitivities of this subject and has gone to considerable lengths to inform its members and to encourage evidence-based debate. You are, surely, aware of the in-depth study which the Association carried out in 2016 ("End of Life Care and Physician-Assisted Dying") and in which both public and doctors' attitudes to 'assisted dying' were carefully researched.

More generally, we deplore the BMJ's wholly one-sided nature of the presentation of this complex and controversial subject. Every article but one featured in the recent issue advocates a change in the law. The exception is a Head to Head debate between Sir Terence English and Lord Bernard Ribeiro. Your editorial refers to this briefly but is otherwise concerned wholly with presenting a case for changing the law. A journal such as the BMJ should provide a forum for objective, dispassionate and balanced discussion of issues relevant to clinical practice. It is hard to regard your recent coverage of this subject as measuring up even remotely to this standard.

Though we are aware that the BMJ does not speak for the BMA or for doctors at large (that is the role of the BMA) and that it is not the Association's house journal, that is not how many members of the public may see the matter. Your treatment of this subject will have left many people with the wholly erroneous impression that the medical profession is moving towards support of legalisation of 'assisted dying'. So far as our own Association is concerned, there is no evidence at all whatever to support such a view.

We look forward to receiving your comments and your answers to the questions concerning the October poll.

In the meantime, we are copying this letter to the Chair of Council of the BMA.

Dr Amy Proffitt
Honorary Secretary to The Association For Palliative Medicine of Great Britain and Northern Ireland
On Behalf of The Association for Palliative Medicine

Firstly, as someone else has pointed out, it's possible to vote more than once (by deleting cookies).

Secondly, the poll follows an article that gives only one (very pro-euthanasia) view. To be valid, both sides of the debate need to be fairly presented.

Other surveys have shown that polls are swayed by the information given at the time of the survey.

As such, to say that the vote of the BMA ARM is not valid is non-sense. As the article here states: "BMA policy is made at its annual representatives meeting (ARM), where delegates vote after listening to debates" - ie, listening to opposing views.

On that basis the vote of the ARM is far more valid than this technically flawed poll.

Competing interests:
I uphold the Hippocratic Oath: "I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect".

Paschalides is concerned about the BMJ removing the 'like' button. In my comment, just six places down, the reality of the potential abuses is made clearer. It is blatantly misleading to compare the non-binding votes on a website to properly conducted ballots either of professional body members or the public.

This debate all comes down to the right to have a choice. Some opponents of AD not only oppose having a choice but also the whole process of deciding whether we have the right to that choice. The argumentum ad populum has been denigrated, but the smaller scale unrepresentative, closed and protectionist stance of some the opposing medical institutions is venerated.

Imagine if it were the other way around. The medical bodies and parliament support AD, and it is legal, but the majority of Drs and the public oppose it. With the shoe on the other foot opponents would more than welcome the very same process of open and fair decision making that supporters seek now. This is hypocrisy.

Whatever lies behind opponents firmly held beliefs, personal, moral, ethical, religious, if they are so sure they are right then they should not fear or oppose open debate and decision making. Adopting high-handed we-know-best attitudes does nothing to help their cause.

Competing interests:
I am opposed to minorities controlling the majority.

In contrast to the clear mandate from the public, it is apparent that there is no consensus on assisted dying in the medical profession; in good conscience, there are differences between doctors. This debate is best informed by a variety of medical voices alongside those of our patients. To present the medical profession through the BMA as wholly opposed to assisted dying is to misrepresent the views of many doctors. We can't know quite how many because the BMA has so far refused a ballot of all members. We do know that there is room for doubt as to which view is in the minority.

The question as to whether or not there should be a legislative framework for assisted dying is not a monochrome debate. Those of us in favour of such a framework recognise that there are obvious pitfalls and dangers in legalising the active ending of a person's life even as we see the dangers in maintaining the status quo that fails many people. We argue simultaneously for a robust legal framework to protect and support people desperate enough to seek to end their lives alongside conscience opt-outs for our colleagues.

Disappointingly, there are some who oppose assisted dying whose actions do not demonstrate a reciprocal respect for those who disagree with them. Some have argued passionately for the BMA to take a firmly oppositional stance. The 'just say no' contingent have positioned the BMA in such a way as to disable it from engaging in constructive discussion, in a debate that goes beyond the medical profession, but which is informed by medical expertise. Intentional or not, this approach has served to suppress the voices of those who don't share their firm conviction that Assisted Dying is wrong and must not be contemplated.

Current BMA policy suppresses representative articulation of reasonable concerns from some doctors that the status quo is dangerous. The BMA is prevented from sharing with parliamentarians the concerns from some members that the absence of a legislative framework for assisted dying leaves patients more vulnerable to abuse, not less. A robust legal framework would ensure that patients' own views must be heard before they are helped to die by compassionate relatives; currently prosecutors only start listening for patients' voices once they are dead. A robust framework would open the door to some patients to express their desperation to their doctor, who may be able to provide the extra help they need to want to go on living. The BMA is unable to articulate the experience of many of its members: that a few patients, whose views are abundantly clear, and whose suffering is not amenable to adequate palliation, are simply more vulnerable to awful suffering without a robust assisted dying law.

The BMA has not shirked from taking a neutral position on other contentious matters on which the profession is divided. The discussion about assisted dying is not going away any time soon; the BMA membership is not united in opposition, so let's stop pretending that it is. At the very least the BMA should poll its full membership on a matter so important to its members, and many of our patients.

Competing interests:
Member of Healthcare Professionals for Assisted Dying
Chair of the Secular Medical Forum of the National Secular Society

While the BMJ supports votes and the weight of doctors' majority opinion, it has recently removed the "like" button from articles written/submitted to its site. Why is that?
While the system - like any system - could have been vulnerable to abuse, isn't that rather contrary to the ethos recommended here, of putting weight on polls, while dismissing popularity of medical opinion?

Sleep is likened to death.
Anyone who has seen a young child struggling to fall asleep, feels that when the child does finally fall asleep, it's like the calm after the storm.
Anyone who has worked in Palliative care could probably relate to the above, even if they haven't had children.

There are parents who have lost their patience with their pre-sleep phase child, and interfered with the process.